Our clinic will file all insurance claims, and benefits will be assigned to Fiebiger Chriopractic. Any insurance copay or deductible amount is due at the time of treatment.
Medicare and supplemental insurance will be filed by our clinic, and benefits will be assigned to Fiebiger Chriopractic. Medicare does not pay for exams, x-rays, or physiotherapies. If medicare supplement does not pay for the above services, medicare patients will be billed directly for services rendered.
Patients injured at work need to file an injury report with thier employer. North Dakota Workers Compensation pays for medically justified chiropractic treatment for 12 treatments or 90 days, which ever comes first. Requests for palliative care are available if medically necessary.
Patients injured in an automobile must report their accident to their auto insurance carrier irregardless which vehicle was at fault. Benefits will be assigned to Fiebiger Chiropractic.
Medical Assistance patients may be financialy responsible for exam, physiotherapy, and manipulation copay amounts depending on financial status as determined by Medical Assistance.
Chiropractic charges are to be paid in full at the time of each treatment unless other arrangements are made with Fiebiger Chiropractic. The cash rate is $65.00 for the initial examination and chiropractic treatment, and $30.00 for future visits, if paid on date of service, however, if not paid on date of service, an additional $5.00 fee will apply. Fees are subject to change without notice
If a balance remains, statements are mailed out as we receive insurance payments. Unpaid balances 90 days or older may be transferred to a collection agency with a $25.00 collection fee. NSF checks will be subject to a $25.00 fee.
PATIENT SIGNATURE: ____________________________________ DATE: _____________________
GUARDIAN SIGNATURE: __________________________________ DATE: _____________________
PATIENT SIGNATURE: ____________________________________ DATE: ______________
GUARDIAN SIGNATURE: ____________________________________ DATE: ______________
FIEBIGER CHIROPRACTIC REPRESENTATIVE & DATE: _______________________________
